BY W. CLAY BROWN, M.D., ABAM, Medical Director, Memorial Hermann Prevention & Recovery Center
Addiction is a brain disease that manifests itself physically, behaviorally, and socially, touching all age groups, education levels, professions, and income levels. Addiction does not discriminate, and it is not uncommon. Approximately 1 in 7 or 40 million Americans age 12 and older have addictions to nicotine, alcohol, or other drugs – more than heart disease, diabetes, or cancer.
Over 50% of all visits to hospital emergency departments can be linked directly to alcohol or drug use. Alcohol kills more teenagers than all other drugs combined while overdose deaths in all age groups from prescription pain relievers have quadrupled since 1999. In 2014, 27.5 million people needed treatment for addiction to alcohol or non-nicotine drugs, but only 11.6% received any form of treatment.
Anyone can develop dependency from prolonged use of addictive medications, especially opioid pain relievers, sleep aids, stimulants and anxiety-reducing drugs, but for many the prolonged use of these powerful substances has unintended consequences and can lead to misuse and overuse. It is as if someone “flipped a switch” in the brain. Eventually, life begins to revolve around obtaining and using the drug at the expense of their personal, professional, family, and spiritual life.
Young adults are facing a lot of challenges right now, including a resurgence of one of the most addictive illicit drugs we have ever seen: heroin. While heroin use has escalated dramatically in recent years across the country regardless of gender, income level, insurance status, and age, it doubled for 18 to 25 year olds from 2002 to 2013, according to the Centers for Disease Control and Prevention (CDC).
During that same span of time, heroinrelated overdose deaths nearly quadrupled nationwide. In 2014, the Texas Department of State Health Services reported that more than 40 percent of heroin-related admissions to its service providers were in their 20’s. Many of those addicted to heroin inject the drug putting them at risk of contracting diseases like hepatitis and HIV.
The trajectory heroin use has taken is in part a byproduct of the prescription painkiller epidemic. Nearly 80 percent of heroin users reported using prescription opioids like OxyContin, Vicodin, and Percocet, according to the National Institute of Drug Abuse (NIDA). People addicted to prescription opioids are 40 times more likely to be addicted to heroin, based on a National Survey on Drug Use and Health report. Complicating things further, heroin has become a cheaper option to prescription opioids. It is getting easier to find, is more lethal, and is highly addictive—all of which make it more cause for concern.
Mixed in with this bad news is some good news: there are effective treatments for addiction, but it takes a lot of work and there is no easy path. Most treatment approaches involve transitioning the person from drug use to abstaining from addictive drugs. Like any effective disease management program, you cannot rely on just taking medications to manage the symptoms. You also have to change the way you do things, modify behaviors, and engage in healthier activities, much like persons with heart disease, diabetes, and other chronic health conditions must do to manage their conditions.
The primary objective of treatment is to help individuals gain recovery from addictive substances, including alcohol. Not only do you address the core issues either being complicated by or contributing to someone’s use of drugs and alcohol, but you help them build a strong support system, often incorporating participation in 12-step programs, to maintain abstinence while learning to manage their condition. Since every aspect of someone’s life is impacted by addiction, it takes a comprehensive biopsycho- social-spiritual approach to rebuild a healthy life.
Treatment is usually covered through health insurance plans and there have been some coverage gains in recent years. The Mental Health Parity and Addiction Equity Act of 2008 sought to make the insurance benefits for addiction treatment services equal to those included in medical policies. Then the Affordable Care Act in 2010 mandated that all insurance policies provide coverage for mental health and substance use disorders. Even with those congressional actions, it is still a challenge for many people to gain the full use of their insurance benefits when seeking treatment due to restrictions and limitations.
The criteria insurers use to authorize treatment is usually based on medical necessity. Unfortunately, addiction’s grip does not end with the physical and medical conditions that go with managing withdrawal. Sometimes, insurance policies stop short of covering the amount of treatment that is warranted. The behavioral, emotional, and cognitive issues need to be addressed, and this takes some time. There is no quick fix for addiction, and it takes a whole person approach.
Besides treatment, more can be done to prevent or reduce the risks for addiction. Late last month, the CDC issued new guidelines concerning prescription opioids. The intent of the guidelines is to reduce the number of opiate prescriptions being issued, to reduce the dosages being prescribed, and to encourage the prescription of nonaddictive medications for treating pain conditions. There are many alternative therapies, procedures, and medications that are highly effective in treating chronic and temporary pain. Physicians need to become more aware of them and make these options available to their patients.
With so much public and media attention being focused on addiction comes new recognition for those who specialize in researching and treating it. Last month the American Board of Medical Specialties (ABMS) recognized Addiction Medicine as a new subspecialty. The American Board of Preventive Medicine (ABPM) sponsored Addiction Medicine as a multi-specialty subspecialty and certification available to any physician certified by a member board of the ABMS. This event recognizes addiction as a preventable and treatable disease.
The disease of addiction is becoming less stigmatized and more recognized as a primary chronic disease of the brain. It is a dysfunction of the brain’s reward, motivation, and memory centers. It is reflected in an individual pathologically pursuing reward and relief by substance use or other behaviors. Addictions may be characterized by impairment, cravings, diminished recognition of significant problems with behavior and interpersonal relationships, and dysfunctional emotional responses. Addiction resembles other chronic diseases with a cycle of relapse and remission, is progressive and is often fatal if untreated.
Addiction is treatable. The destructive tendencies and consequences associated with addiction can be interrupted and the earlier the intervention, the better. Detox, inpatient and outpatient treatment, individual counseling, therapy, medications, and recovery support services are among the many options available. Not everyone who enters the treatment continuum enters at the same stage or requires the same level of intensity. But it is important to remember that people do recover and regain their quality of life.
Sources: http://www.cdc.gov/vitalsigns/heroin/file:///C:/Users/e1534269/Downloads/SenateHHSPres-RXDrugAbuse%20(1).pdf http://archive.samh sa.gov/d at a/2k13/ DAWN127/sr127-DAWN-highlights.htm http://www.census.gov/newsroom/pressreleases/2014/cb14-219.html
If you are human, you are susceptible to addiction
BY JASON POWERS, MD, member, American Board of Addiction Medicine, CMO, Promises Austin drug rehab program and The Right Step addiction treatment centers
Throughout time and across cultures, mindand mood-altering substances have often been considered to be “gifts of the gods.” Drugs are used in healing, religious, and other culturally significant ceremonies. People have used, do use, and will continue to use these substances because they exert potent effects in the pleasure and survival pathways of the brain, capturing our attention like nothing else. They provide a powerful, effective, and easy way to change how we feel.
Drugs are thus not only used to make us feel better; they are also used as tools, coping devices, and as an escape. In the right alignment of drug, person, and environment, drugs enslave. This, in turn, causes great pain and destruction. As many as 15% of those who use alcohol and other drugs develop the disease of addiction.
Addiction isn’t just about the drugs
In the United States, some 23 million people fulfill the diagnostic criteria for substance addiction, but most do not receive treatment. Many end up dead or in jail. Addiction is a chronic, relapsing, and potentially fatal disease that imposes vast social as well as individual and family costs. Continued use of mind- and mood-altering substances is not sufficient by itself to explain the disease of addiction. Addiction is a multifaceted illness with contributing factors that extend beyond merely using too much for too long. In the right person and under the right circumstances, however, drugs powerfully and, in some ways, permanently change the chemistry in the brain when addiction is activated.
Recall the analogy of cucumbers and pickles: cucumbers can always become pickles, but pickles can never return to being cucumbers. Studies of the brain and its structures involved in drug use, tolerance, pleasure, withdrawal, and relapse provide clear evidence that the relationship between the addict and the object of his or her addiction involves neural pathways that permeate the whole person —body, mind and soul. At the neurochemical level, the disease primarily affects the mesolimbic dopamine system (MDS), but this, in turn, affects every aspect of the person, including his or her environments and relationships.
Addiction comes about with genetic, psychological, and environmental predispositions. Repeated exposure results in a neurochemically changed brain. Addiction is possible in anyone; it does not target the poor, the dumb, or the “bad.” If you are human, you are susceptible. As with other chronic diseases like diabetes or high blood pressure, the chances of developing addiction increase if you have low socioeconomic status, co-occurring mental health issues, or inadequate social and family support systems.
Choice vs. disease debate is dead
Moreover, the choice-versus-disease debate should be over. Reliable scientific research has provided the data to move us past archaic explanations about addiction and addicts. Imaging studies and microscopic molecular research have identified dysfunctional reward, motivation, and impulse-control mechanisms, along with other factors, which explain the behaviors that are symptomatic of the disease.
Addiction is no longer a mystery — it is a disease-causing dysfunction in the MDS, a part of the brain that functions below the level of conscious choice. Addiction resides in the primitive recesses of our brains that focus on survival, operating independently of our will. Chemical reactions in the MDS excite and captivate the bundle of cells that evolved to motivate us to repeat behaviors such as eating and sex that help us survive and pass on our genes.
Once addiction commandeers this part of the brain, it robs the person of his or her free will, specifically because the MDS operates subconsciously through a stimulusresponse mechanism. When this happens, our frontal lobes, the most highly evolved parts of our brain that give us the awareness to make choices, are not as in charge as we would like to believe. There may have been elements of choice during the development of addiction, but there are also substantial elements of choice in other chronic diseases. What separates addiction from other chronic diseases is that volition is lost at some point along the continuum of use, abuse, and dependence.
The initial choice to use or experiment with drugs or processes is voluntary (although the drive to self-medicate increases the propensity to make that choice), but the effects of drugs and processes in the brain are profoundly influenced by genetic, environmental, and other factors beyond the addict’s control. However, it is important to stress that classifying addiction as a disease does NOT relieve the addict of personal responsibility and accountability for his or her behavior and its effects on others. Addiction is complex; it is not solely a behavioral problem, a biological problem, a psychological problem, or a spiritual problem. Addiction is a dysfunction in all of these systems.
The honeymoon phase
At first, drugs and processes may serve the person well. Drugs, sex, gambling, and food can be effective and powerful coping tools that relieve stress, provide pleasure, or otherwise offer an escape. These choices are fraught with danger, however. Before long, those coping tools commandeer and change the brain, activating addiction.
When that line has been crossed, it is too late to ever go back; once someone develops the disease of addiction, he or she will always have it. There is no cure, and it never goes away. However, an addict, any addict, does not have to continue to suffer in active addiction — recovery is possible.
Treating addiction is effective.
More than 30 years of research demonstrates that addiction responds to treatment. It should also be clear that punishing addiction does not work. In order to truly measure treatment’s effectiveness, it is important to look at the management of other chronic diseases. Comparing addiction treatment to the treatment of other chronic diseases reveals that management of addiction is as effective as management of high blood pressure and diabetes. Due to the limitations set by managed care or one’s own resources, many patients receive less than the recommended level of care.
Treatment that is inadequate is usually ineffective, and failure is likely. When patients are able to receive appropriate treatment and follow the recommended care, they have positive outcomes. Addiction is a relapsing disease, but so are other chronic diseases. Approximately 60% of patients with high blood pressure or asthma and 40% of patients with diabetes experience relapse of their symptoms and require more intensive care.
This makes clear the fallacy that if an addict relapses after treatment, treatment for addiction does not work. In the treatment community, we know that each therapeutic intervention adds to an evolving process of learning and growing. We see treatment work, and we know not to give up before the miracle of healing happens.